Nutrition and Physical Activity                                               Topic 37 
                
               Module 37.2 
                
               Physical Activity and Chronic Diseases 
                
                                                                              Julie Mareschal-Douissard 
                                                                           BSc in Nutrition and Dietetics 
                                                         Clinical Nutrition, Geneva University Hospital 
                                                                Rue Micheli-du-Crest 24, 1211 Geneva 
                                                                                               Switzerland 
                                                                                                              
                                                                                              Emilie Reber 
                                                             PhD, Swiss federally certified pharmacist 
                                                                              
                                                               Departmentof diabetes, endocrinology, 
                                                    nutritional medicine and metabolism, Inselspital 
                                                      Bern University Hospital and University of Bern 
                                                                          Freiburgstrasse 15, 3010 Bern 
                                                                                               Switzerland 
                
               Learning Objectives 
                
                   Impact  of  physical  fitness  and  physical  exercise  on  the  secondary  prevention  of 
                    selected  chronic diseases;  
                   Impact of physical exercise and nutritional support on selected chronic diseases;  
                   Contraindication to physical activity in selected chronic diseases; 
                   Recommendations for physical activity in selected chronic diseases. 
                
               Contents 
                
               1.   Introduction 
               2.   Physical activity for secondary prevention of CD associated with malnutrition 
                    2.1. Chronic heart failure (CHF) 
                        2.1.1. CHF and physical fitness 
                        2.1.2. Benefits of physical activity on CHF 
                        2.1.3. Impact of physical activity and nutrition on CHF 
                        2.1.4. Contraindications to/Adverse effects of physical activity in CHF 
                        2.1.5. Recommendations on physical activity in CHF 
                    2.2 Cancer 
                        2.2.1. Cancer and physical fitness 
                        2.2.2. Benefits of physical activity on cancer 
                        2.2.3. Impact of physical activity and nutrition on cancer 
                        2.2.4. Contraindications to/Adverse effects of physical activity in cancer 
                        2.2.5. Recommendations on physical activity in cancer 
                    2.3 Chronic obstructive pulmonary disease (COPD) 
                        2.3.1. COPD and physical fitness 
                        2.3.2. Benefits of physical activity on COPD 
                        2.3.3. Impact of physical activity and nutrition on COPD 
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                           2.2.4. Contraindications to/Adverse effects of physical activity in COPD 
                           2.3.5. Recommendations on physical activity in COPD 
                 3.   Physical activity for secondary prevention in metabolic syndrome 
                      3.1 Metabolic syndrome and physical fitness 
                      3.2 Benefits of physical activity on metabolic syndrome 
                      3.3 Impact of physical activity and nutrition on metabolic syndrome 
                      3.4 Contraindications to/Adverse effects of physical activity in metabolic syndrome 
                      3.5 Recommendations on physical activity in metabolic syndrome 
                 4.   Conclusions 
                 5.   References  
                  
                 Key Messages 
                  
                     Physical  fitness  includes  body  composition,  muscle  strength  and  endurance, 
                      cardiorespiratory fitness and flexibility; 
                     Regular physical activity positively affects physical fitness and clinical outcome in 
                      patients with heart failure, chronic obstructive pulmonary disease and cancer; 
                     Multimodal treatment combining physical activity and nutritional support improves 
                      outcome in chronic obstructive disease patients; 
                     No  studies  evaluated  the  impact  of  physical  activity  and  nutritional  support  in 
                      malnourished heart failure patients; 
                     Some recommendations for physical activity are available for heart failure, cancer 
                      patients and patients with metabolic syndrome. 
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              1. Introduction 
                  
              Physical activity is defined as any body movement produced by skeletal muscles that 
              increases energy expenditure (1). It includes exercise and other activities performed at 
              work, for transport, domestic duties and in leisure time (2).  
              Non-communicable chronic diseases, termed for ease as chronic diseases (CD), are the 
              cause of over 70% of overall worldwide deaths representing about 40 million deaths each 
              year (3). The major CD related to mortality are, respectively, cardiovascular diseases (17.8 
              million deaths), cancers (9.6 million deaths), chronic respiratory diseases (3.9 million 
              deaths), neurological disorders (3.1 million deaths) and diabetes and kidney diseases (2.6 
              million deaths). The mortality related to CD is expected to rise in the next decades and to 
              cause 77% of deaths by 2030 (4). Furthermore, CD lead to an increased economic burden 
              related to healthcare consumption and loss of labour days, estimated over the period 2011-
              2030 at US $47 trillion (5).  
              The World Health Report, undertaken by the World Health Organization (WHO), reported 
              the 10 main risk factors related to CD burden (6). In developed countries, the four major 
              modifiable risk factors are poor diet, physical inactivity, smoking, and harmful alcohol use.  
              This module focuses on the importance of physical activity in the secondary prevention of 
              selected  CD  associated  with  malnutrition  and  in  metabolic  syndrome,  considered  in 
              combination with nutritional support, when this information is available.  
               
              2. Physical Activity for Secondary Prevention of Cd Associated with 
                 Malnutrition 
               
              This chapter aims to highlight the importance of physical activity and exercise, in addition 
              to nutritional support, in the management of chronic diseases associated with malnutrition. 
              We will focus on chronic heart failure, cancer and chronic obstructive pulmonary disease 
              (COPD) as they are the major CD related to mortality.  
              According to the European Society of Clinical Nutrition and Metabolism (ESPEN), the term 
              “malnutrition” includes disease-related malnutrition with and without inflammation, and 
              malnutrition without disease (Fig. 1) (7). 
               
                                                                                               
                                   Fig. 1 Classification of malnutrition concepts 
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               Recently, malnutrition has been defined by the Global Leadership Initiative on Malnutrition 
               (GLIM) as the association of one phenotypic criterion (body weight loss, low body mass 
               index  (BMI),  or  reduced  muscle  mass)  and  one  aetiological  criterion  (reduced  food 
               intake/assimilation or inflammation/disease burden) (8).  
                
               2.1.  Chronic Heart Failure (CHF) 
                
               The  European  Society  of  Cardiology  defines  heart  failure  as  “a  clinical  syndrome 
               characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that 
               may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles 
               and peripheral oedema) caused by a structural and/or functional cardiac abnormality, 
               resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or 
               during stress” (9). In developed countries, the prevalence of heart failure ranges from 1 
               to  10%  of  the  population  according  to  the  age  range  and  the  definition  used  (9). 
               Approximately  80%  of  patients  with  CHF  are  at  risk  of  malnutrition,  while  overt 
               malnutrition occurs in 10% of patients. The one-year mortality of patients with CHF and 
               malnutrition ranges from 20 to 40% (10). 
                
               2.1.1. CHF and Physical Fitness 
                
               Patients with CHF suffer from decreased functional capacities and exercise intolerance. The 
               pathophysiological mechanisms are multifactorial (11): 
                   -   Reduced cardiorespiratory fitness:  cardiac reserve (systolic, diastolic and left 
                       atrial  dysfunctions, functional mitral regurgitation) and  pulmonary reserve ( 
                       pulmonary vasodilation and vascular recruitment,  O  alveolar diffusion, abnormal 
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                       ventilation reserve and regulation) 
                   -   Reduced muscular strength  and  endurance:  switch  of  type  I  to  type  II  fibre, 
                       mitochondrial dysfunction,  capillary density,  oxidative enzymes 
                   -   Altered body composition:  skeletal muscle mass,  intermuscular fat. 
                
               The relationship between CHF and physical fitness is bidirectional. Poor cardiorespiratory 
               fitness has been associated with a higher risk of CHF (12) and CHF-associated mortality 
               (13)  in  subjects  healthy  at  baseline  and  of  mortality  in  subjects  with  CHF  (14). 
               Interestingly,  cardiorespiratory  fitness  may  better  predict  cardiovascular  events  than 
               physical activity (15).  
               In malnourished CHF patients, cardiorespiratory fitness and muscle mass are decreased 
               compared to CHF patients without malnutrition (16). Moreover, peak VO  is also a predictor 
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               of mortality. 
                
               2.1.2. Benefits of Physical Activity on CHF 
                
               A recent Cochrane systematic review included randomised controlled trials  comparing 
               exercise interventions (aerobic training alone and aerobic plus resistance) with a follow-up 
               of ≥6 months vs. no exercise control, in adults with CHF (17). Exercise reduced all-cause 
               mortality  at  >12  months  follow-up,  overall  hospital  admissions  and  CHF-specific 
               hospitalisation during the first year of follow-up and improved quality of life. However, 
               there was no impact on all-cause mortality at 12 months follow-up. 
               The other benefits of combined endurance and resistance training or of endurance training 
               alone are: 
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